Basic Information
| Provider Information | |||||||||
| NPI: | 1164562187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EREN | ||||||||
| FirstName: | MUAZZEZ | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2264 | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983620223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605650215 | ||||||||
| FaxNumber: | 3604578429 | ||||||||
| Practice Location | |||||||||
| Address1: | 519 S PEABODY ST STE 6 | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983626247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605650215 | ||||||||
| FaxNumber: | 3604578429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | RC00026296 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 591906 | 05 | WA | MEDICAID |